Forms

For your convenience, our most commonly used physician and provider forms are available below. Just click on the applicable form, complete online, print, and then mail or fax to us. Also included below are commonly used member forms that you can provide to our members as a courtesy when needed.

Physician and Provider Forms

• 835 Health Care Electronic Remittance Advice (ERA) Request Form (PDF)
• Adult Problem List (PDF)
• Behavioral Health Outpatient Treatment Plan Form (PDF)
• Billing Authorization Professional Association Form (PDF)
• Case Management Referral Form (PDF)
• Claim Overpayment Refund Form (PDF)
• Coding Assistance Request Form (PDF)
• CVS Caremark Specialty Pharmacy Enrollment Form (PDF)
• Electronic Funds Transfer Registration Form (PDF)
• Fee Schedule Request Form (PDF)
• Healthy Addition Prenatal Program High Risk Member Log (PDF)
• National Provider Identifier (NPI) Notification Form (PDF)
• Pediatric/Adolescent Problem List (PDF)
• Provider Appeal Form (PDF)
• Provider Claim Inquiry Form (PDF)
• Provider Information Update Form (PDF)
• Provider Registration Form (PDF)
• Skilled Nursing Facility Select Medication Program Order Form (PDF)

Member Forms

Members can access a variety of member-related forms online by registering with MyBlueService^SM, our member self-service website.

• Accident Letter (PDF)
  This form is used by your patients to furnish BCBSF with information if they have recently experienced a claim due to an accident.
• Other Insurance Information Form (PDF)
  This form is used by your patients to update their Other Insurance or Medicare information with BCBSF. This form is only to be completed and submitted by our members.
• The Advance Directives - Living Will: English version | Spanish version (PDF)
  This form may be distributed to your patients to assist them in conveying their life planning and care decisions to family, friends and health care professionals.
• BCBSA COB Questionnaire (PDF)
  This form can be used by your out-of-state patients to update their Other Insurance or Medicare information with their Home Blue Plan. This form is only to be completed and submitted by Non-BCBSF members.
• Authorization for Mental Health Providers to Release Medical Information (PDF)
  This form can be used by members to authorize mental health providers to release their medical record information. Please note BCBSF does not require the submission of proof of authorization to release clinical information.